Vaccination Guidelines for Special Populations

Introduction to Herpes Zoster Vaccination

• The American Academy of Microbiology, Immunology and Infection, along with the American College of Physicians, American Academy of Family Physicians, and Centers for Disease Control and Prevention (CDC), recommends vaccination with the recombinant zoster vaccine (RZV, Shingrix) for adults, including those with a history of herpes zoster, with a minimum interval of 2 months after the acute episode 1, 2, 3, 4

Eligibility and Administration

• The recombinant zoster vaccine (RZV, Shingrix) is administered as a 2-dose series, with a minimum interval of 2 months after an acute herpes zoster episode before vaccination, and a shortened dosing interval of 1-2 months between doses is recommended for immunocompromised adults, as supported by the Infectious Diseases Society of America 1, 5, 6, 7, 8, 9, 10
• Adults ≥50 years without a history of varicella or with an unclear history should receive the herpes zoster vaccine, preferably RZV, and individuals with proven seronegativity for the varicella-zoster virus should receive immunization with 2 doses of varicella vaccine, 4 weeks apart, according to the American Academy of Microbiology, Immunology and Infection 1

Vaccine Effectiveness

• The effectiveness of Shingrix is 97.2% in adults ≥50 years and 91.3% in adults ≥70 years, with a cumulative incidence of recurrence after 10 years being 10.3%, as reported by the American College of Physicians and the CDC 1, 2, 5
• The following table compares the effectiveness of different vaccines:

5

• The following table compares the efficacy of different vaccines:

3, 9

Special Considerations

• Live vaccines, including Zostavax, are contraindicated in immunosuppressed patients, including those on corticosteroids, purine analogues, methotrexate, and biologic therapies, as recommended by the American Gastroenterological Association, and immunomodulators should be withheld for 4 weeks after live vaccine administration 11
• Shingrix is a safe option for immunocompromised patients due to its non-live recombinant subunit formulation, according to the American College of Immunology and American Autoimmune Association, and is recommended for adults ≥50 years to prevent herpes zoster and its complications 5, 2, 1, 3, 4
• For patients who have completed chemotherapy, vaccination with Shingrix can be initiated 3 months after completion of chemotherapy, as recommended by the Infectious Diseases Society of America, and for patients who received anti-CD20 antibody therapy, consider delaying vaccination until at least 6 months after the last dose 12, 2
• For patients who underwent autologous hematopoietic stem cell transplant, vaccination with Shingrix can begin 3-12 months post-transplant, as suggested by the American Society for Transplantation and Cellular Therapy 2

Safety and Co-administration

• Shingrix is safe for immunocompromised patients as it cannot cause infection, making it a preferred option for patients with a history of NHL, and has a higher incidence of grade 3 injection site reactions and systemic symptoms compared to placebo, but most reactions are transient and mild to moderate in severity 5, 1
• If a patient previously received Zostavax, they should still receive the complete Shingrix series (minimum interval of 8 weeks after Zostavax) 5, 1
• Co-administration with other vaccines (e.g., influenza) is safe but may increase the risk of side effects and decrease adherence to influenza vaccination in the following year, and current bone infection is not a contraindication for Shingrix, but active, severe acute infection with high fever may require temporary deferral until fever resolves 1, 6, 7, 13